Skip to main content
SpringerLink
Log in
Book cover

Pharmacological Treatment of Acute Coronary Syndromes pp 185–212Cite as

Triple Therapy: Risky but Sometimes Necessary

  • Chapter
  • First Online:

  • 1389 Accesses

Part of the book series: Current Cardiovascular Therapy ((CCT))

Abstract

Triple therapy defined by use of aspirin, a P2Y12 inhibitor and oral anticoagulation can be indicated in certain clinical situations but usually for a limited period of time to prevent serious thrombotic events as stroke, recurrent MI, stent-thrombosis, and death. The typical clinical situation: a patient with a clear indication of oral anticoagulation experiencing an acute MI or is treated with PCI. Combinational use of oral anticoagulation and antiplatelet therapy increases the risk of bleeding, both when considering triple therapy with vitamin k antagonists, aspirin and clopidogrel and triple therapy with a novel anticoagulant (rivaroxaban, apixaban, and dabigatran). Occurrence of a bleeding is followed by an increased risk of thromboses and death. Recommended duration of triple therapy is dependent on presence/absence of acute coronary syndrome, risk of bleeding and type of stent used in patients treated with PCI. These parameters should be evaluated before initiation and duration of triple therapy is determined. For triple therapy combinations of vitamin K antagonist or dabigatran 110 mg, aspirin and clopidogrel can be used. Triple therapy including rivaroxaban (in doses used for oral anticoagulation), apixaban, ticagrelor, or prasugrel can currently not be recommended.

This is a preview of subscription content, log in via an institution.

Chapter
USD   29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD   39.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD   49.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Learn about institutional subscriptions

References

  1. Sorensen R, Hansen ML, Abildstrom SZ, Hvelplund A, Andersson C, Jorgensen C, et al. Risk of bleeding in patients with acute myocardial infarction treated with different combinations of aspirin, clopidogrel, and vitamin K antagonists in Denmark: a retrospective analysis of nationwide registry data. Lancet. 2009;374(9706):1967–74.

    Article  PubMed  CAS  Google Scholar 

  2. Dewilde WJ, Oirbans T, Verheugt FW, Kelder JC, De Smet BJ, Herrman JP, et al. Use of clopidogrel with or without aspirin in patients taking oral anticoagulant therapy and undergoing percutaneous coronary intervention: an open-label, randomised, controlled trial. Lancet. 2013;381:1107–15.

    Article  PubMed  CAS  Google Scholar 

  3. Yusuf S, Zhao F, Mehta SR, Chrolavicius S, Tognoni G, Fox KK. Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation. N Engl J Med. 2001;345(7):494–502.

    Article  PubMed  CAS  Google Scholar 

  4. Wallentin L, Becker RC, Budaj A, Cannon CP, Emanuelsson H, Held C, et al. Ticagrelor versus clopidogrel in patients with acute coronary syndromes. N Engl J Med. 2009;361(11):1045–57.

    Article  PubMed  CAS  Google Scholar 

  5. Wiviott SD, Braunwald E, McCabe CH, Montalescot G, Ruzyllo W, Gottlieb S, et al. Prasugrel versus clopidogrel in patients with acute coronary syndromes. N Engl J Med. 2007;357(20):2001–15.

    Article  PubMed  CAS  Google Scholar 

  6. Connolly SJ, Ezekowitz MD, Yusuf S, Eikelboom J, Oldgren J, Parekh A, et al. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med. 2009;361(12):1139–51.

    Article  PubMed  CAS  Google Scholar 

  7. Granger CB, Alexander JH, McMurray JJ, Lopes RD, Hylek EM, Hanna M, et al. Apixaban versus warfarin in patients with atrial fibrillation. N Engl J Med. 2011;365(11):981–92.

    Article  PubMed  CAS  Google Scholar 

  8. Patel MR, Mahaffey KW, Garg J, Pan G, Singer DE, Hacke W, et al. Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. N Engl J Med. 2011;365(10):883–91.

    Article  PubMed  CAS  Google Scholar 

  9. Karjalainen PP, Porela P, Ylitalo A, Vikman S, Nyman K, Vaittinen MA, et al. Safety and efficacy of combined antiplatelet-warfarin therapy after coronary stenting. Eur Heart J. 2007;28(6):726–32.

    Article  PubMed  CAS  Google Scholar 

  10. Ruiz-Nodar JM, Marin F, Hurtado JA, Valencia J, Pinar E, Pineda J, et al. Anticoagulant and antiplatelet therapy use in 426 patients with atrial fibrillation undergoing percutaneous coronary intervention and stent implantation implications for bleeding risk and prognosis. J Am Coll Cardiol. 2008;51(8):818–25.

    Article  PubMed  CAS  Google Scholar 

  11. Jensen-Urstad K, Bouvier F, Hojer J, Ruiz H, Hulting J, Samad B, et al. Comparison of different echocardiographic methods with radionuclide imaging for measuring left ventricular ejection fraction during acute myocardial infarction treated by thrombolytic therapy. Am J Cardiol. 1998;81(5):538–44.

    Article  PubMed  CAS  Google Scholar 

  12. Rao SV, O’Grady K, Pieper KS, Granger CB, Newby LK, Van de Werf F, et al. Impact of bleeding severity on clinical outcomes among patients with acute coronary syndromes. Am J Cardiol. 2005;96(9):1200–6.

    Article  PubMed  Google Scholar 

  13. Eikelboom JW, Mehta SR, Anand SS, Xie C, Fox KA, Yusuf S. Adverse impact of bleeding on prognosis in patients with acute coronary syndromes. Circulation. 2006;114(8):774–82.

    Article  PubMed  Google Scholar 

  14. Hamm CW, Bassand JP, Agewall S, Bax J, Boersma E, Bueno H, et al. ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: The Task Force for the management of acute coronary syndromes (ACS) in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J. 2011;32(23):2999–3054.

    Article  PubMed  Google Scholar 

  15. Steg PG, James SK, Atar D, Badano LP, Blomstrom-Lundqvist C, Borger MA, et al. ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J. 2012;33(20):2569–619.

    Article  PubMed  CAS  Google Scholar 

  16. Gurbel PA, Bliden KP, Hiatt BL, O’Connor CM. Clopidogrel for coronary stenting: response variability, drug resistance, and the effect of pretreatment platelet reactivity. Circulation. 2003;107(23):2908–13.

    Article  PubMed  Google Scholar 

  17. Serebruany VL, Steinhubl SR, Berger PB, Malinin AI, Bhatt DL, Topol EJ. Variability in platelet responsiveness to clopidogrel among 544 individuals. J Am Coll Cardiol. 2005;45(2):246–51.

    Article  PubMed  CAS  Google Scholar 

  18. O’Donoghue M, Wiviott SD. Clopidogrel response variability and future therapies: clopidogrel: does one size fit all? Circulation. 2006;114(22):e600–6.

    Article  PubMed  Google Scholar 

  19. Fefer P, Hod H, Matetzky S. Clopidogrel resistance–the cardiologist’s perspective. Platelets. 2007;18(3):175–81.

    Article  PubMed  CAS  Google Scholar 

  20. Shuldiner AR, O’Connell JR, Bliden KP, Gandhi A, Ryan K, Horenstein RB, et al. Association of cytochrome P450 2C19 genotype with the antiplatelet effect and clinical efficacy of clopidogrel therapy. JAMA. 2009;302(8):849–57.

    Article  PubMed  CAS  Google Scholar 

  21. Storey RF, Husted S, Harrington RA, Heptinstall S, Wilcox RG, Peters G, et al. Inhibition of platelet aggregation by AZD6140, a reversible oral P2Y12 receptor antagonist, compared with clopidogrel in patients with acute coronary syndromes. J Am Coll Cardiol. 2007;50(19):1852–6.

    Article  PubMed  CAS  Google Scholar 

  22. Wallentin L, Varenhorst C, James S, Erlinge D, Braun OO, Jakubowski JA, et al. Prasugrel achieves greater and faster P2Y12 receptor-mediated platelet inhibition than clopidogrel due to more efficient generation of its active metabolite in aspirin-treated patients with coronary artery disease. Eur Heart J. 2008;29(1):21–30.

    Article  PubMed  CAS  Google Scholar 

  23. Lip GY, Huber K, Andreotti F, Arnesen H, Airaksinen JK, Cuisset T, et al. Antithrombotic management of atrial fibrillation patients presenting with acute coronary syndrome and/or undergoing coronary stenting: executive summary–a Consensus Document of the European Society of Cardiology Working Group on Thrombosis, endorsed by the European Heart Rhythm Association (EHRA) and the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J. 2010;31(11):1311–8.

    Article  PubMed  Google Scholar 

  24. Ong AT, McFadden EP, Regar E, de Jaegere PP, van Domburg RT, Serruys PW. Late angiographic stent thrombosis (LAST) events with drug-eluting stents. J Am Coll Cardiol. 2005;45(12):2088–92.

    Article  PubMed  CAS  Google Scholar 

  25. Stone GW, Moses JW, Ellis SG, Schofer J, Dawkins KD, Morice MC, et al. Safety and efficacy of sirolimus- and paclitaxel-eluting coronary stents. N Engl J Med. 2007;356(10):998–1008.

    Article  PubMed  CAS  Google Scholar 

  26. Pfisterer M, Brunner-La Rocca HP, Buser PT, Rickenbacher P, Hunziker P, Mueller C, et al. Late clinical events after clopidogrel discontinuation may limit the benefit of drug-eluting stents: an observational study of drug-eluting versus bare-metal stents. J Am Coll Cardiol. 2006;48(12):2584–91.

    Article  PubMed  CAS  Google Scholar 

  27. Park DW, Park S-W, Park K-H, Lee B-K, Kim Y-H, Lee CW, Hong M-K, Kim J-J, Park S-J. Frequency of and risk factors for stent thrombosis after drug-eluting stent implantation during long-term follow-up. Am J Cardiol. 2006;98:352–6.

    Article  PubMed  Google Scholar 

  28. Valgimigli M, Campo G, Percoco G, Monti M, Ferrari F, Tumscitz C, et al. Randomized comparison of 6- versus 24-month clopidogrel therapy after balancing anti-intimal hyperplasia stent potency in all-comer patients undergoing percutaneous coronary intervention Design and rationale for the PROlonging Dual-antiplatelet treatment after Grading stent-induced Intimal hyperplasia study (PRODIGY). Am Heart J. 2010;160(5):804–11.

    Article  PubMed  CAS  Google Scholar 

  29. Park SJ, Park DW, Kim YH, Kang SJ, Lee SW, Lee CW, et al. Duration of dual antiplatelet therapy after implantation of drug-eluting stents. Eur Heart J. 2010;362(15):1374–82.

    CAS  Google Scholar 

  30. Eisenstein EL, Anstrom KJ, Kong DF, Shaw LK, Tuttle RH, Mark DB, et al. Clopidogrel use and long-term clinical outcomes after drug-eluting stent implantation. Jama. 2007;297(2):159–68.

    Article  PubMed  CAS  Google Scholar 

  31. Connolly S, Pogue J, Hart R, Pfeffer M, Hohnloser S, Chrolavicius S, et al. Clopidogrel plus aspirin versus oral anticoagulation for atrial fibrillation in the Atrial fibrillation Clopidogrel Trial with Irbesartan for prevention of Vascular Events (ACTIVE W): a randomised controlled trial. Lancet. 2006;367(9526):1903–12.

    Article  PubMed  CAS  Google Scholar 

  32. Hart RG, Pearce LA, Aguilar MI. Meta-analysis: antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation. Ann Intern Med. 2007;146(12):857–67.

    Article  PubMed  Google Scholar 

  33. Acar J, Iung B, Boissel JP, Samama MM, Michel PL, Teppe JP, et al. AREVA: multicenter randomized comparison of low-dose versus standard-dose anticoagulation in patients with mechanical prosthetic heart valves. Circulation. 1996;94(9):2107–12.

    Article  PubMed  CAS  Google Scholar 

  34. Cannegieter SC, Rosendaal FR, Wintzen AR, van der Meer FJ, Vandenbroucke JP, Briet E. Optimal oral anticoagulant therapy in patients with mechanical heart valves. N Engl J Med. 1995;333(1):11–7.

    Article  PubMed  CAS  Google Scholar 

  35. Bauersachs R, Berkowitz SD, Brenner B, Buller HR, Decousus H, Gallus AS, et al. Oral rivaroxaban for symptomatic venous thromboembolism. N Engl J Med. 2010;363(26):2499–510.

    Article  PubMed  CAS  Google Scholar 

  36. Lagerstedt CI, Olsson CG, Fagher BO, Oqvist BW, Albrechtsson U. Need for long-term anticoagulant treatment in symptomatic calf-vein thrombosis. Lancet. 1985;2(8454):515–8.

    Article  PubMed  CAS  Google Scholar 

  37. Schulman S, Granqvist S, Holmstrom M, Carlsson A, Lindmarker P, Nicol P, et al. The duration of oral anticoagulant therapy after a second episode of venous thromboembolism. The Duration of Anticoagulation Trial Study Group. N Engl J Med. 1997;336(6):393–8.

    Article  PubMed  CAS  Google Scholar 

  38. Kearon C, Ginsberg JS, Kovacs MJ, Anderson DR, Wells P, Julian JA, et al. Comparison of low-intensity warfarin therapy with conventional-intensity warfarin therapy for long-term prevention of recurrent venous thromboembolism. N Engl J Med. 2003;349(7):631–9.

    Article  PubMed  CAS  Google Scholar 

  39. Douketis JD. Combination warfarin-ASA therapy: which patients should receive it, which patients should not, and why? Thrombo Res. 2011;127(6):513–7.

    Article  CAS  Google Scholar 

  40. Buresly K, Eisenberg MJ, Zhang X, Pilote L. Bleeding complications associated with combinations of aspirin, thienopyridine derivatives, and warfarin in elderly patients following acute myocardial infarction. Arch Intern Med. 2005;165(7):784–9.

    Article  PubMed  CAS  Google Scholar 

  41. Hurlen M, Abdelnoor M, Smith P, Erikssen J, Arnesen H. Warfarin, aspirin, or both after myocardial infarction. N Engl J Med. 2002;347(13):969–74.

    Article  PubMed  CAS  Google Scholar 

  42. Lamberts M, Olesen JB, Ruwald MH, Hansen CM, Karasoy D, Kristensen SL, et al. Bleeding after initiation of multiple antithrombotic drugs, including triple therapy, in atrial fibrillation patients following myocardial infarction and coronary intervention: a nationwide cohort study. Circulation. 2012;126(10):1185–93.

    Article  PubMed  Google Scholar 

  43. Nguyen MC, Lim YL, Walton A, Lefkovits J, Agnelli G, Goodman SG, et al. Combining warfarin and antiplatelet therapy after coronary stenting in the Global Registry of Acute Coronary Events: is it safe and effective to use just one antiplatelet agent? Eur Heart J. 2007;28(14):1717–22.

    Article  PubMed  CAS  Google Scholar 

  44. Van de Werf F, Bax J, Betriu A, Blomstrom-Lundqvist C, Crea F, Falk V, et al. Management of acute myocardial infarction in patients presenting with persistent ST-segment elevation: the Task Force on the Management of ST-Segment Elevation Acute Myocardial Infarction of the European Society of Cardiology. Eur Heart J. 2008;29(23):2909–45.

    Article  PubMed  Google Scholar 

  45. Fuster V, Ryden LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA, et al. ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Circulation. 2006;114(7):e257–354.

    Article  PubMed  Google Scholar 

  46. Hansen ML, Sorensen R, Clausen MT, Fog-Petersen ML, Raunso J, Gadsboll N, et al. Risk of bleeding with single, dual, or triple therapy with warfarin, aspirin, and clopidogrel in patients with atrial fibrillation. Arch Intern Med. 2010;170(16):1433–41.

    Article  PubMed  CAS  Google Scholar 

  47. Alexander JH, Lopes RD, James S, Kilaru R, He Y, Mohan P, et al. Apixaban with antiplatelet therapy after acute coronary syndrome. N Engl J Med. 2011;365(8):699–708.

    Article  PubMed  CAS  Google Scholar 

  48. Oldgren J, Budaj A, Granger CB, Khder Y, Roberts J, Siegbahn A, et al. Dabigatran vs. placebo in patients with acute coronary syndromes on dual antiplatelet therapy: a randomized, double-blind, phase II trial. Eur Heart J. 2011;32(22):2781–9.

    Article  PubMed  CAS  Google Scholar 

  49. Mega JL, Braunwald E, Wiviott SD, Bassand JP, Bhatt DL, Bode C, et al. Rivaroxaban in patients with a recent acute coronary syndrome. N Engl J Med. 2012;366(1):9–19.

    Article  PubMed  CAS  Google Scholar 

  50. Mega JL, Braunwald E, Mohanavelu S, Burton P, Poulter R, Misselwitz F, et al. Rivaroxaban versus placebo in patients with acute coronary syndromes (ATLAS ACS-TIMI 46): a randomised, double-blind, phase II trial. Lancet. 2009;374(9683):29–38.

    Article  PubMed  CAS  Google Scholar 

  51. Dans AL, Connolly SJ, Wallentin L, Yang S, Nakamya J, Brueckmann M, et al. Concomitant use of antiplatelet therapy with dabigatran or warfarin in the randomized evaluation of long-term anticoagulation therapy (RE-LY) trial. Circulation. 2013;127(5):634–40.

    Article  PubMed  CAS  Google Scholar 

  52. Lip GY, Huber K, Andreotti F, Arnesen H, Airaksinen KJ, Cuisset T, et al. Management of antithrombotic therapy in atrial fibrillation patients presenting with acute coronary syndrome and/or undergoing percutaneous coronary intervention/ stenting. Thromb Haemost. 2010;103(1):13–28.

    Article  PubMed  CAS  Google Scholar 

  53. Camm AJ, Lip GY, De Caterina R, Savelieva I, Atar D, Hohnloser SH, et al. 2012 focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation. Developed with the special contribution of the European Heart Rhythm Association. Eur Heart J. 2012;33(21):2719–47.

    Article  PubMed  Google Scholar 

  54. Pisters R, Lane DA, Nieuwlaat R, de Vos CB, Crijns HJ, Lip GY. A novel user-friendly score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation: the Euro Heart Survey. Chest. 2010;138(5):1093–100.

    Article  PubMed  Google Scholar 

  55. Gage BF, Yan Y, Milligan PE, Waterman AD, Culverhouse R, Rich MW, et al. Clinical classification schemes for predicting hemorrhage: results from the National Registry of Atrial Fibrillation (NRAF). Am Heart J. 2006;151(3):713–9.

    Article  PubMed  Google Scholar 

  56. Fang MC, Go AS, Chang Y, Borowsky LH, Pomernacki NK, Udaltsova N, et al. A new risk scheme to predict warfarin-associated hemorrhage: the ATRIA (Anticoagulation and Risk Factors in Atrial Fibrillation) Study. J Am Coll Cardiol. 2011;58(4):395–401.

    Article  PubMed  Google Scholar 

  57. Subherwal S, Bach RG, Chen AY, Gage BF, Rao SV, Newby LK, et al. Baseline risk of major bleeding in non-ST-segment-elevation myocardial infarction: the CRUSADE (Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA Guidelines) Bleeding Score. Circulation. 2009;119(14):1873–82.

    Article  PubMed  Google Scholar 

  58. Moscucci M, Fox KA, Cannon CP, Klein W, Lopez-Sendon J, Montalescot G, et al. Predictors of major bleeding in acute coronary syndromes: the Global Registry of Acute Coronary Events (GRACE). Eur Heart J. 2003;24(20):1815–23.

    Article  PubMed  CAS  Google Scholar 

  59. Olesen JB, Lip GY, Hansen PR, Lindhardsen J, Ahlehoff O, Andersson C, et al. Bleeding risk in ‘real world’ patients with atrial fibrillation: comparison of two established bleeding prediction schemes in a nationwide cohort. J Thromb Haemost. 2011;9(8):1460–7.

    Article  PubMed  CAS  Google Scholar 

  60. Apostolakis S, Lane DA, Guo Y, Buller H, Lip GY. Performance of the HEMORR 2 HAGES, ATRIA, and HAS-BLED bleeding risk-prediction scores in nonwarfarin anticoagulated atrial fibrillation patients. J Am Coll Cardiol. 2013;61(3):386–7.

    Article  PubMed  Google Scholar 

  61. Amador P, Santos JF, Goncalves S, Seixo F, Soares L. Comparison of ischemic and bleeding risk scores in non-ST elevation acute coronary syndromes. Acute Card Care. 2011;13(2):68–75.

    Article  PubMed  Google Scholar 

  62. Ho PM, Maddox TM, Wang L, Fihn SD, Jesse RL, Peterson ED, et al. Risk of adverse outcomes associated with concomitant use of clopidogrel and proton pump inhibitors following acute coronary syndrome. JAMA. 2009;301(9):937–44.

    Article  PubMed  CAS  Google Scholar 

  63. O’Donoghue ML, Braunwald E, Antman EM, Murphy SA, Bates ER, Rozenman Y, et al. Pharmacodynamic effect and clinical efficacy of clopidogrel and prasugrel with or without a proton-pump inhibitor: an analysis of two randomised trials. Lancet. 2009;374(9694):989–97.

    Article  PubMed  Google Scholar 

  64. Charlot M, Ahlehoff O, Norgaard ML, Jorgensen CH, Sorensen R, Abildstrom SZ, et al. Proton-pump inhibitors are associated with increased cardiovascular risk independent of clopidogrel use: a nationwide cohort study. Ann Intern Med. 2010;153(6):378–86.

    Article  PubMed  Google Scholar 

  65. Bhatt DL, Cryer BL, Contant CF, Cohen M, Lanas A, Schnitzer TJ, et al. Clopidogrel with or without omeprazole in coronary artery disease. N Engl J Med. 2010;363(20):1909–17.

    Article  PubMed  CAS  Google Scholar 

  66. Abraham NS, Hlatky MA, Antman EM, Bhatt DL, Bjorkman DJ, Clark CB, et al. ACCF/ACG/AHA 2010 Expert Consensus Document on the concomitant use of proton pump inhibitors and thienopyridines: a focused update of the ACCF/ACG/AHA 2008 expert consensus document on reducing the gastrointestinal risks of antiplatelet therapy and NSAID use: a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents. Circulation. 2010;122(24):2619–33.

    Article  PubMed  Google Scholar 

  67. Hallas J, Dall M, Andries A, Andersen BS, Aalykke C, Hansen JM, et al. Use of single and combined antithrombotic therapy and risk of serious upper gastrointestinal bleeding: population based case–control study. BMJ. 2006;333(7571):726.

    Article  PubMed  Google Scholar 

  68. Sarafoff N, Ndrepepa G, Mehilli J, Dorrler K, Schulz S, Iijima R, et al. Aspirin and clopidogrel with or without phenprocoumon after drug eluting coronary stent placement in patients on chronic oral anticoagulation. J Intern Med. 2008;264(5):472–80.

    Article  PubMed  CAS  Google Scholar 

  69. Rossini R, Musumeci G, Lettieri C, Molfese M, Mihalcsik L, Mantovani P, et al. Long-term outcomes in patients undergoing coronary stenting on dual oral antiplatelet treatment requiring oral anticoagulant therapy. Am J Cardiol. 2008;102(12):1618–23.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Cardiology, Copenhagen University Hospital Bispebjerg, Bispebjerg Bakke 23, København, NV, 2400, Denmark

    Rikke Sørensen MD, PhD

  2. Department of Cardiology, Copenhagen University Hospital Gentofte, Hellerup, Denmark

    Gunnar Gislason MD, PhD

Authors
  1. Rikke Sørensen MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Gunnar Gislason MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Rikke Sørensen MD, PhD .

Editor information

Editors and Affiliations

  1. Servicio de Cardiología, Hospital Universitario Central de Asturias, Oviedo, Spain

    Pablo Avanzas

  2. Department of Cardiology, The Heart Center, Rigshospitalet University Hospital of Copenhagen,, Copenhagen, Denmark

    Peter Clemmensen

Rights and permissions

Reprints and permissions

Copyright information

© 2014 Springer-Verlag London

About this chapter

Cite this chapter

Sørensen, R., Gislason, G. (2014). Triple Therapy: Risky but Sometimes Necessary. In: Avanzas, P., Clemmensen, P. (eds) Pharmacological Treatment of Acute Coronary Syndromes. Current Cardiovascular Therapy. Springer, London. https://doi.org/10.1007/978-1-4471-5424-2_6

Download citation

  • DOI: https://doi.org/10.1007/978-1-4471-5424-2_6

  • Published:

  • Publisher Name: Springer, London

  • Print ISBN: 978-1-4471-5423-5

  • Online ISBN: 978-1-4471-5424-2

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation